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COVID-19 Impact On Antimicrobial Resistance · The SHEA Podcast

• 0:08
  SPEAKER_00: Welcome to the Rapid Response Podcast brought to you by the Society for Healthcare Epidemiology of America, Shay, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:24
  SPEAKER_00: I'm Dr.
• 0:24
  SPEAKER_00: Jennifer Hanrahan, infectious disease specialist at the University of Toledo, and I will serve as your moderator.
• 0:30
  SPEAKER_00: Discussion on the podcast does not reflect Shay's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:40
  SPEAKER_00: Shay is excited to launch this episode of the podcast, COVID-19 updates, What We Know Now.
• 0:45
  SPEAKER_00: Today's discussion will focus on the impact of COVID-19 on antimicrobial resistance.
• 0:51
  SPEAKER_00: Our speaker today is David Van Dyne, Associate Professor of Medicine in the Division of Infectious Diseases and Director of the Immunocompromised Host Infectious Diseases section at the University of North Carolina Chapel Hill School of Medicine.
• 1:06
  SPEAKER_00: Thank you for joining us today.
• 1:08
  SPEAKER_00: Before we start our discussion, I would like to get us started with a brief news and guidance update for the week.
• 1:14
  SPEAKER_00: As of April 7, 2021, there have been 131,837,512 confirmed cases of COVID-19, including 2,862,664 deaths reported to the World Health Organization.
• 1:30
  SPEAKER_00: As of April 5th, 2021, a total of 604,032,357 vaccine doses have been administered globally, including 168,592,075 doses of vaccine in the United States.
• 1:46
  SPEAKER_00: In a letter to the New England Journal of Medicine, researchers describe antibody persistence through six months after the second dose of Moderna vaccine for COVID-19.
• 1:55
  SPEAKER_00: The vaccine-elicited binding and neutralizing antibodies were described in 33 healthy adult participants in an ongoing phase one trial, stratified according to age, at 180 days after the second dose of vaccine, day 209.
• 2:09
  SPEAKER_00: Antibody activity remained high in all age groups at day 209.
• 2:13
  SPEAKER_00: Binding antibodies measured by means of an enzyme-linked immunosorbent assay against SARS-CoV-2 spike receptor binding domain had geometric mean endpoint titers of 92,451 in participants 18 to 55 years of age, 62,424 in those 56 to 70 years of age, and 49,373 in those 71 years of age or older.
• 2:36
  SPEAKER_00: Although the antibody titers and assays that best correlate with vaccine efficacy are not currently known, antibodies that were licensed by the Moderna vaccine persisted through six months after the second dose.
• 2:46
  SPEAKER_00: Ongoing studies are monitoring immune responses beyond six months, as well as determining the effect of a booster dose to extend the duration and breadth of activity against emerging viral variants.
• 2:57
  SPEAKER_00: A study published in the Lancet describes six-month neurological and psychiatric outcomes and 236,379 survivors of COVID-19.
• 3:06
  SPEAKER_00: This retrospective cohort study used data obtained from electronic health records among 236,379 patients diagnosed with COVID-19.
• 3:15
  SPEAKER_00: The estimated incidence of a neurological or psychiatric diagnosis in six months following diagnosis with COVID-19 was 33.62% overall.
• 3:25
  SPEAKER_00: For patients who had been admitted to an ICU, the estimated incidence of a diagnosis was 46.42%.
• 3:32
  SPEAKER_00: And for a first diagnosis was 25.79%.
• 3:36
  SPEAKER_00: In the group with ICU admission, estimated incidences were 2.66 for inocranial hemorrhage, 6.92 for ischemic stroke, 0.26 for Parkinsonism, 1.74 for dementia, 19.15 for anxiety disorder, and 2.77 for psychotic disorder.
• 3:53
  SPEAKER_00: Hazard ratios were higher in patients who had more severe COVID-19.
• 4:02
  SPEAKER_00: The guidance states that in most situations, the risk of infection from touching a surface is low.
• 4:07
  SPEAKER_00: The most reliable way to prevent infection from surfaces is to regularly wash hands or use hand sanitizer.
• 4:13
  SPEAKER_00: Cleaning and disinfecting services can also reduce the risk of infection.
• 4:17
  SPEAKER_00: This guidance is indicated for buildings in community settings and is not intended for healthcare settings or for other facilities where specific regulations or practices for cleaning and disinfection may apply.
• 4:28
  SPEAKER_00: When no people with confirmed or suspected COVID-19 are known to have been in a space, cleaning once a day is usually enough to sufficiently remove virus that may be on surfaces and help maintain a healthy facility.
• 4:40
  SPEAKER_00: More frequent cleaning or disinfection may be considered in shared spaces when there are conditions that could increase the risk of infection, such as high transmission of COVID-19 in the community, low number of people wearing masks, infrequent hand hygiene, or the spaces occupied by certain populations, such as people at increased risk for severe illness from COVID-19.
• 5:01
  SPEAKER_00: If there has been a sick person or someone who tested positive for COVID-19 in the facility within the last 24 hours, cleaning and disinfection is recommended.
• 5:09
  SPEAKER_00: The guidance also states that the effectiveness of alternative disinfection methods such as ultrasonic waves, high-intensity UV radiation, and LED blue light against the virus that causes COVID-19 has not been fully established.
• 5:22
  SPEAKER_00: CDC does not recommend the use of sanitizing tunnels, and in most cases, fogging, fumigation, and wide area electrostatic spraying is not recommended.
• 5:31
  SPEAKER_00: The CDC has also updated guidance for fully vaccinated people on April 2nd.
• 5:36
  SPEAKER_00: In addition to prior recommendations, fully vaccinated people can resume domestic travel and refrain from testing before after travel or self-quarantine after travel, refrain from testing before leaving the United States for international travel unless required by the destination, and refrain from self-quarantine after arriving back in the United States.
• 5:53
  SPEAKER_00: The guidance states of fully vaccinated people should continue to follow precautions in public settings and get tested if experiencing symptoms.
• 6:01
  SPEAKER_00: And that's the news for this week.
• 6:03
  SPEAKER_00: I now want to move on to the discussion with our speaker.
• 6:07
  SPEAKER_00: Thank you for joining us, Dr.
• 6:08
  SPEAKER_00: Van Dyne.
• 6:09
  SPEAKER_00: My pleasure.
• 6:11
  SPEAKER_00: First, can you tell our listeners about some of the work that you do and research you conduct in antimicrobial resistance?
• 6:18
  SPEAKER_01: Yeah, so I'm an infectious disease physician.
• 6:21
  SPEAKER_01: And for my research, part of my job, I'm interested in resistance in gram-negative bacteria.
• 6:27
  SPEAKER_01: And as part of that research, I work with a large team of investigators to do observational studies, mostly in hospitalized patients, on those highly resistant bacteria with a focus on carbapenum resistant enthobacteralis.
• 6:43
  SPEAKER_01: I also have some studies going on that look at the spread within communities of these types of bacteria.
• 6:50
  SPEAKER_00: In September 2020, you published an article on the impact of COVID-19 pandemic on antimicrobial resistance.
• 6:57
  SPEAKER_00: What are some key takeaways from that?
• 7:00
  SPEAKER_01: So that article was an introduction to a pro-con debate that we published in the journal Jack AMR.
• 7:06
  SPEAKER_01: And this debate was about what the impact hypothetically could be of the pandemic on AMR rates.
• 7:14
  SPEAKER_01: In the pro-s they argued that the pandemic can be associated with increased antibiotic use, increased antibacterial use, and also inappropriate antibacterial use, which of course is one of the main drivers of antimicrobial resistance.
• 7:32
  SPEAKER_01: However, in the in the counties, they argued that the pandemic is also associated with less travel, distancing, people washing their hands more frequently, and those kinds of things, which actually may result in less spread of these resistant bacteria that are sort of already out there.
• 7:50
  SPEAKER_01: So after resistance has already formed, those types of interventions may cause less spread, and therefore the pandemic may actually have a net result of a decrease in AMR rates.
• 8:01
  SPEAKER_00: So, you know, as you mentioned, early on, there was some overuse of antibiotics because of clinical uncertainty around management of COVID-19 in hospitalized patients and also now patients.
• 8:13
  SPEAKER_00: How do we learn from this, not only for impact of antimicrobial distortion, but for future pandemics?
• 8:19
  SPEAKER_01: Yeah, I think that that's just a very important issue that we really want to think about now and especially as we get this pandemic hopefully under control.
• 8:31
  SPEAKER_01: It is very difficult, of course, to know how to deal with a completely new pathogen.
• 8:37
  SPEAKER_01: And I think hindsight is always 2020 and looking back and saying, oh, you know, we shouldn't have given that many antibiotics is relatively easy to do.
• 8:45
  SPEAKER_01: But when you're faced with a critically ill patient and you don't know what is going on or what may benefit, that's a very difficult clinical decision to make.
• 8:54
  SPEAKER_01: I think the key take-home point that I see in all of this, from my perspective, is that the earlier we can get randomized controlled trials set up to evaluate the best possible treatment options in a new setting.
• 9:09
  SPEAKER_01: If a new emerging or re-emerging pathogen should come up, the better it is.
• 9:14
  SPEAKER_01: And to try to include as many patients that are eligible into those types of studies where appropriate.
• 9:21
  SPEAKER_01: I think we've certainly learned from COVID that that is possible and that really the most reliable information will come from those types of studies.
• 9:29
  SPEAKER_00: So one of the biggest difficulties, you know, that we're experiencing is that it's hard to tell the difference between sepsis sometimes from coronavirus and sepsis due to bacterial and fungal infections.
• 9:43
  SPEAKER_00: And so, you know, could this contribute to antibiotic overuse?
• 9:46
  SPEAKER_00: And do you have any recommendations on how to avoid this?
• 9:49
  SPEAKER_01: Yeah, we we definitely need better diagnostics in infectious diseases.
• 9:54
  SPEAKER_01: Most of our diagnostics, as you know, are culture-based and have been culture-based for decades.
• 10:00
  SPEAKER_01: There's a lot of development in rapid diagnostics.
• 10:04
  SPEAKER_01: There are very promising new technologies, including those types of diagnostics that can diagnose directly from a sample, so directly from blood, or directly from putum, or things like that.
• 10:15
  SPEAKER_01: That being said, diagnostics in and of themselves are not going to necessarily move the needle on antibiotic overuse.
• 10:24
  SPEAKER_01: And multiple studies have shown that if you produce a new diagnostic, you really need that antimicrobial stewardship to reinforce what to do with the results to make sure that the people who make the decisions on antibiotic use actually get the results and know sort of how to interpret them.
• 10:41
  SPEAKER_00: Yeah, have you found biomarkers to be at all helpful in this area?
• 10:46
  SPEAKER_01: Biomarkers in COVID, as far as I can tell, have not really been clinically all that useful.
• 10:53
  SPEAKER_01: A lot of biomarkers that we see going up, like CRP and procalcitonin, go up in in COVID, but also go up in bacterial infections and a number of other infections.
• 11:05
  SPEAKER_01: So in my experience, they've they've been of limited use.
• 11:09
  SPEAKER_01: There may, of course, be other biomarkers that are not sort of widely clinically available that might be more useful.
• 11:17
  SPEAKER_00: So, Dr.
• 11:17
  SPEAKER_00: Renett, what are some of the unmet research needs in the area of understanding the impact of COVID-19 on the emergence of antibiotic resistance?
• 11:26
  SPEAKER_01: Yeah, so we don't really have a good understanding yet of what the impact of COVID-19 on AMR rates is going to be.
• 11:35
  SPEAKER_01: I think it will be very interesting to see updated numbers from CDC comparing the time before COVID and after COVID.
• 11:44
  SPEAKER_01: What we have to keep in mind is that in general, AMR rates tend to trend upwards, unfortunately.
• 11:51
  SPEAKER_01: So as a general rule over the last few decades, we of course have seen more resistance rather than less resistance for most bacteria.
• 12:01
  SPEAKER_01: But we're really waiting on sort of national and global surveillance data to get a better sense.
• 12:08
  SPEAKER_01: There are some studies from single centers, and those are sometimes difficult to interpret because it may just reflect what is going on in a particular hospital.
• 12:18
  SPEAKER_01: The other issue is inpatients with COVID who have been diagnosed with COVID infection, there are a lot of reports about bacterial coinfection, and those studies tend to also, for the most part, be single-cellular studies and with limited controls.
• 12:35
  SPEAKER_01: And one of the issues there, which is an issue for a lot of studies, is to determine whether those positive bacterial cultures actually reflect infection versus just colonization, which of course is again made more difficult by the issue that we were just talking about that patients with COVID tend to clinically resemble patients with bacterial substances.
• 12:58
  SPEAKER_00: Besides inappropriate prescription of antibiotics, how has COVID-19 created even more challenges for our healthcare system as it pertains to antimicrobial resistance?
• 13:08
  SPEAKER_01: So one of the very important impacts that I've seen is that the people who've been really pulled away to deal with COVID to hospital level are the same people who are often responsible for antimicrobial stewardship, hospital prevention efforts.
• 13:26
  SPEAKER_01: And those people at baseline, and you know, the people from Shea know this better than anybody else, at baseline, they're not sitting on the couch eating bonbons.
• 13:35
  SPEAKER_01: They're working quite hard, and COVID has just added to that.
• 13:39
  SPEAKER_01: And what I have not heard really from anybody is that additional personnel has been hired in those hospital epidemiology infection prevention departments.
• 13:50
  SPEAKER_01: So it's just a matter of doing more work, much more work with the same amount of personnel.
• 13:56
  SPEAKER_01: And I think that that's a really a tremendous stressor on the system and will make it more difficult to prevent AMR.
• 14:03
  SPEAKER_01: Another issue, although I think it's maybe less of an issue now, but certainly early on in the pandemic was the PPE issue and how much was available, especially on the onset of the pandemic.
• 14:14
  SPEAKER_00: Yeah, I think it's going to be interesting to see, you know, what the benchmarks are going to be coming out of last year, because certainly there were a lot of changes in PPE.
• 14:24
  SPEAKER_00: I think that's a really important point.
• 14:26
  SPEAKER_00: What do you see as some of the opportunities for healthcare systems and professionals to help mitigate these challenges?
• 14:32
  SPEAKER_01: The main opportunity is the one I already alluded to, and that is this possibility of doing clinical research in a good way on a large scale in infectious disease.
• 14:45
  SPEAKER_01: I think we have previously been in a situation where we felt that those types of studies would be very difficult to do in infectious disease, and we've gotten used to working with really limited data and making decisions based on limited data.
• 14:59
  SPEAKER_01: And I think, if nothing else, COVID has shown us that we can do large-scale multi-center randomized controlled trials on important questions in infectious disease.
• 15:09
  SPEAKER_01: And I hope that that trend will continue and that we get a lot more high-quality data to base our decisions on.
• 15:17
  SPEAKER_00: As I'm sure you're aware, there are more than 2.8 million multidrug resistant bacterial infections that occur annually in the United States that lead to at least 35,000 deaths and$20 billion in healthcare expenditures.
• 15:29
  SPEAKER_00: Is there any data to suggest that COVID-19 can and will make these numbers worse?
• 15:34
  SPEAKER_00: And what should our healthcare systems be doing to help improve these numbers?
• 15:37
  SPEAKER_01: So I think it's still too early to tell what the impact will be.
• 15:42
  SPEAKER_01: As we talked about a little bit earlier, there are multiple interactions between COVID and drivers of AMR.
• 15:49
  SPEAKER_01: So on the one hand, more antibiotics, possibly more hospital exposures for certain groups of patients.
• 15:56
  SPEAKER_01: On the other hand, there's also more telemedicine.
• 15:59
  SPEAKER_01: There is less travel, more distancing.
• 16:02
  SPEAKER_01: So you have sort of these two forces that work against each other.
• 16:06
  SPEAKER_01: So it's it's quite possible that the effect may be in either direction.
• 16:10
  SPEAKER_01: Again, we need that data from TTC and from benchmarking studies that you were referring to to see what direction it's going to go in.
• 16:19
  SPEAKER_01: I was looking in in preparation for this podcast at studies that had looked at hospital acquired infection rates, and no clear signal has been elucidated there either that I could find.
• 16:32
  SPEAKER_00: Do you think that because of the pandemic there will be more focus on antibiotic stewardship programs?
• 16:38
  SPEAKER_01: I I certainly would hope so.
• 16:40
  SPEAKER_01: And I I do think so.
• 16:41
  SPEAKER_01: I think that this has shown how important infectious diseases are and always will be that you need to support the people that that work on this in the hospital, but also in the community, and that should remain a focus.
• 16:58
  SPEAKER_00: Okay.
• 16:59
  SPEAKER_00: Do you have any additional or final thoughts on this topic that we didn't cover today?
• 17:04
  SPEAKER_01: No, I just want to uh thank you for inviting me to take part of this podcast.
• 17:10
  SPEAKER_00: Well, thank you very much.
• 17:11
  SPEAKER_00: We really appreciate your sharing your perspective and experiences today.
• 17:16
  SPEAKER_00: This podcast can be accessed on Shay's Online Education Center, Learning CE, under the Rapid Response Program.
• 17:23
  SPEAKER_00: You will also find resources such as the recorded webinars, healthcare facility outbreak preparedness, and the SHAY COVID-19 town halls.
• 17:30
  SPEAKER_00: We would like to let everyone know that we will not be launching a podcast for the next two weeks due to Shea Spring.
• 17:36
  SPEAKER_00: If you are interested in hearing from expert speakers on COVID-19 and other prevalent healthcare epidemiology topics, we encourage you to join us virtually at Shea Spring April 13th through 16th.
• 17:47
  SPEAKER_00: Register now at Shayspring.org.
• 17:50
  SPEAKER_00: This concludes this episode of the Rapid Response Podcast.
• 17:53
  SPEAKER_00: Thank you for tuning in.